1578846598 NPI number — MRS. SHANDA JACKSON FNP-C

Table of content: MRS. SHANDA JACKSON FNP-C (NPI 1578846598)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578846598 NPI number — MRS. SHANDA JACKSON FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
SHANDA
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
FNP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RICHARDSON
Provider Other First Name:
SHANDA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1578846598
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/30/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1089
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAMMOND
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70404-1089
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
985-892-7070
Provider Business Mailing Address Fax Number:
985-892-7017

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6569 HIGHWAY 84
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FERRIDAY
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71334-4573
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-892-7070
Provider Business Practice Location Address Fax Number:
855-821-4499
Provider Enumeration Date:
09/26/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  AP06672 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: R855819 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 09503346 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2319248 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: F0711469 . This is a "CERTIFICATION NUMBER" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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